The Workers' Compensation System is designed to protect workers from economic hardship caused by work-related injury or disease. The WCB system is a no-fault insurance program designed to protect both the worker and employer. This historical compromise provides work related benefits to workers injured in the course of employment and protects employers, who pay the premiums, from lawsuits. As a rule all employers are required by law to provide WCB coverage.
What to do if you get injured at work.
If you were injured at work, the first thing you must do is immediately notify your employer. Do not wait until the next day or after a weekend. If you are working alone or unsupervised call your employer. If the injury is serious in any way, immediately go to a clinic or hospital and see a doctor. Your claim could be denied if you fail to notify your employer and seek medical attention.
There are three basic types of compensation claims.
- no time-loss health care claims
- short term time-loss injury claims
- long term time-loss case management claims
A no time-loss health care claim occur when a worker returns to work after seeing a doctor or the next work day. The employer pays the workers wages for the day of injury and WCB covers the medical costs.
A client service representative at the initial call centre usually handles a short-term injury claim and benefits are usually paid for up to 3 weeks.
A long term time-loss case management claims deal with more serious injuries that are expected to last more then 4 weeks and there are concerns or problems returning to work.
My claim was denied!
It is unfortunate, but claims are denied for many different reasons. When a worker fails to immediately report an injury or seek medical attention, the claim can be viewed as questionable action on part of the worker and evidence to deny the claim. Another common reason denying a claim is lack of or poor medical evidence to support the injury. To often doctors generalize or use buzz words to describe an injury, such as disc degeneration or arthritis. These types of medical terms are often seen as natural ailments and not sufficient to establish causation of injury. When seeing a doctor make certain the medical information being submitted is as specific as possible.
What most workers fail to realize is that workers' compensation providers are in the insurance business and there are numerous factors beyond the workers control that influence the decision making process. These factors include legislation, corporate mandate, budget restraints and adjudication workloads. Some adjudicators are so over worked they simply do not have the time to investigate the accident; they may simply rely on a quick facts checklist to reach a decision. That is why it is so important for a worker to immediately report an injury and seek medical attention.
The number one factor that influences the decision making process is the perception of fraud. It is well documented that fraudulent injury claims cost insurance companies billions of dollars a year. Fraud prevention is taken very seriously in the insurance industry. Adjudicators are trained to look for and identify suspicious events or focus on certain types of injuries. This unfortunately can create a bias in the decision making process, especially if bonuses or rewards are posted to individuals that report or identify a fraudulent claim.
If there is any doubt as to the validity of your claim, you should contact your adjudicator and ask for a meeting to clarify any doubts or unanswered questions. It would also be wise to consult an advocate or workers' advisor first and if possible have them attend the meeting. Word of advice, try to avoid getting frustrated, angry or confrontational, this type of behavior often makes the matter worse. A poor relationship between the worker and the adjudicator can and often does affect the final decision.
I can't work and WCB won't help.
If your claim has been denied you do have the right to appeal the decision. Contact your local WCB or advocacy group to get the necessary information. Before you file an appeal, it is best to seek claim advice from an advocate or workers' advisor and if possible have them summit the appeal. If you are in immediate need of financial assistance, numerous government agencies provide income assistance benefits. Contact your local service centre for more information.
If you have additional information you would like to share with us please contact administration.
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